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Day of Month12345678910111213141516171819202122232425262728293031
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Day of Week
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Email Address
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First Name
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Middle Name
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Last Name
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Date of Completion of this form
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CIRS Overview Outline00
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Anxiety Avg;#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!
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Pain Avg:#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!
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Depression/Mood Score#DIV/0!0000000000000000000000000000000
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Clusters0000000000000000000
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Symptom Days (SD)
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SD Health Score %
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MCAS Symptom Days#DIV/0!
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MCAS Health Index%#DIV/0!
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ISEAI Pearls
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Combined CIRS & MCAS
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Headache#DIV/0!
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Confusion#DIV/0!
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Red Eyes#DIV/0!
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Watery Eyes#DIV/0!
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Blurred Vision#DIV/0!
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Dizziness/Vertigo#DIV/0!
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Diarrhea#DIV/0!
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Abdominal Pain#DIV/0!
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Bloating/IBS#DIV/0!
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Frequent urination#DIV/0!
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Bone pain#DIV/0!
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Joint Pain#DIV/0!
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Muscle Pain#DIV/0!
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Sweats#DIV/0!
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Chills#DIV/0!
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Anxiety & ADL#DIV/0!
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Rate your level of Anxiety at present (1-No Anxiety to 10-Very Intense Anxiety)#DIV/0!
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Generally, how much does your Anxiety problem interfere with your Day-To-Day Activities? (1-No Interference to 10-Extreme Interference)#DIV/0!
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Since the time you developed your Anxiety problem how much has your Anxiety changed your Ability to Work? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety changed the amount of Satisfaction or Enjoyment you get from Participating in Social and Recreational Activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety changed your Ability to Participate in Recreational and other Social Activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety changed the amount of Satisfaction you get from Family Related Activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety affected your overall Mood? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety affected your overall Sleep? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety affected your Ability to do Household Chores? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your Anxiety changed the amount of Satisfaction or Enjoyment you get from Work? (1-No Change to 10-Extreme Change)#DIV/0!
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How well controlled is your anxiety? (1-Good Control, 10-Out of Control)#DIV/0!
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Pain & ADL#DIV/0!
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Rate level of Pain at present (1-No Pain to 10-Very Intense Pain)#DIV/0!
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Generally, how much does your pain problem interfere with your Day-To-Day Activities? (1-No Interference to 10-Extreme Interference)#DIV/0!
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Since the time you developed a pain problem, how much has your pain changed your Ability To Work? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain changed the amount of Satisfaction or Enjoyment you get from Participating in Social and Recreational Activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain changed your Ability to Participate in Recreational and other Social Activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain changed the amount of Satisfaction you get from Family Related Activities? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain affected your overall Mood? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain affected your overall Sleep? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain affected your Ability to do Household Chores? (1-No Change to 10-Extreme Change)#DIV/0!
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How much has your pain changed the amount of Satisfaction or Enjoyment you get from Work? (1-No Change to 10-Extreme Change)#DIV/0!
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How well controlled is your pain (1-No Control, 10-Extreme Control)#DIV/0!
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Mood & ADL#DIV/0!
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Little or no interest in doing things (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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Feeling down, depressed, or hopeless (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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Trouble falling or staying asleep or sleeping to much (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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Feeling tired or having little energy (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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Poor appetite or over-eating (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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Feeling bad about yourself — or that you are a failure or have let yourself or your family down (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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Trouble concentrating on things, such as reading the newspaper or watching television (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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Thoughts that you would be better off dead or of hurting yourself in some way (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people (0=not at all, 1=several days, 2=more than half of the days, 3=nearly every day)?#DIV/0!
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Chronic Inflammatory Response Syndrome (CIRS) Questions;
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Chronic fatigue0
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Lack of stamina0
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Weakness0
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Decreased assimilation of new knowledge/information0
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Frequent achiness0
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Frequent headache0
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Light sensitivity0
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Decreased recent memory0
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Memory loss0
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Word-finding difficulty0
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Difficulty Concentrating0
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Joint stiffness, especially in the morning0
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Arthritis0
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Cramps0
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Muscle spasms/"clawed" hands & fingers (ADH/Osm)0
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Muscle aches & pains0
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Electrical shock sensation when touching your skin0
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Altered sensation/numbness/tingling0
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Skin changes0
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Shortness of breath at rest0
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Unusual shortness of breath with exertion0
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Sinus problems0
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Cough0
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Frequent thirst0
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Confusion0
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Changes in appetite0
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Temperature regulation problems0
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Urinary frequency0
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Dry eyes/gritty feeling0
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Sudden pains in the eyes0